Basic Information
| Provider Information | |||||||||
| NPI: | 1043866213 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMANDIBUOGU | ||||||||
| FirstName: | KENECHUKWU | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | HHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1731 BUNKER HILL RD NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200173026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026355756 | ||||||||
| FaxNumber: | 2026355780 | ||||||||
| Practice Location | |||||||||
| Address1: | 1731 BUNKER HILL RD NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200173026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2026355756 | ||||||||
| FaxNumber: | 2026355780 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2019 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 374U00000X | HHA14448 | DC | Y | Nursing Service Related Providers | Home Health Aide |
ID Information
| ID | Type | State | Issuer | Description | HHA14448 | 01 | DC | HHA LICENSE | OTHER |